Documentation Time Research Articles

Timeliness of Documentation and Costs of Care in Adults Newly Diagnosed with CKD

Timeliness of Documentation and Costs of Care in Adults Newly Diagnosed with CKD

The impact of nuance DAX ambient listening AI documentation: a cohort study.

To assess the impact of the use of an ambient listening/digital scribing solution (Nuance Dragon Ambient eXperience (DAX)) on caregiver engagement, time spent on Electronic Health Record (EHR) including time after hours, productivity, attributed panel size for value-based care providers, documentation timeliness, and Current Procedural Terminology (CPT) submissions. We performed a peer-matched controlled cohort study from March to September 2022 to evaluate the impact of DAX in outpatient clinics in an integrated healthcare system. Primary outcome measurements included provider engagement survey results, reported patient safety events related to DAX use, patients' Likelihood to Recommend score, number of patients opting out of ambient listening, change in work relative values units, attributed value-based primary care panel size, documentation completion and CPT code submission deficiency rates, and note turnaround time. A total of 99 providers representing 12 specialties enrolled in the study; 76 matched control group providers were included for analysis. Median utilization of DAX was 47% among active participants. We found positive trends in provider engagement, while non-participants saw worsening engagement and no practical change in productivity. There was a statistically significant worsening of after-hours EHR. There was no quantifiable effect on patient safety. Nuance DAX use showed positive trends in provider engagement at no risk to patient safety, experience, or clinical documentation. There were no significant benefits to patient experience, documentation, or measures of provider productivity. Our results highlight the potential of ambient dictation as a tool for improving the provider experience. Head-to-head comparisons of EHR documentation efficiency training are needed.

2049 Evaluating the rate, timeliness and accuracy of centralised Clinical Frailty Score documentation at a major NHS A&E department

Abstract Introduction Between 5-10% of patients attending the emergency department (ED) are elderly patients living with frailty. NHS England now recommends that all patents aged >65 presenting to acute care should have a Clinical Frailty Score documented within 30 minutes of arrival. We audited the CFS documentation from the Electronic Patient Record (EPR) for patients aged >65 presenting to our local E.D. Methods Our baseline audit looked at patients aged >65 presenting to our ED from 01/09/23-07/09/2023 (n=430). We extracted data for rate and timeliness of documentation from EPR. To calculate accuracy, we compared the documented scores from ED triage staff, with that of our therapist led Frailty Intervention Team (FIT). We excluded patients not assessed by the FIT. We then re-audited the data for 3 separate weeks after delivering a tailored teaching session for band 6 and 7 nurses, and introduction of an educational poster. Results We found exceptional baseline compliance and timeliness of CFS scoring with a 97% documentation rate with a median time of 31 mins from presentation. When assessing accuracy of triage nurse CFS documentation, we found that 42% of patients fell into a lower category of frailty when compared to scores allocated by the FIT. Following teaching sessions and poster education, we observed no improvement in this. Conclusion Our audit identified an overall excellent baseline compliance and timeliness in EPR documentation of CFS scores despite the department’s heavy workload. We noted a significant under-recognition of frailty at ED triage compared to specialist therapist scoring. Despite delivering education sessions and introduction of an educational poster there is still significant room for improvement in accurate identification of frailty with the CFS.

Nursing process, derived from the clinical care classification system components, as an earlier indicator of nursing care during a pandemic

BackgroundDuring COVID pandemic response, an early signal was desired beyond typical financial classifications or order sets. The foundational work of Virginia K Saba informed the essential, symbiotic relationship of nursing practice and resource utilization by means of the Clinical Care Classification System [CCC]. Scholars have confirmed the use of the CCC as the structure for data modeling, focusing on the concept of nursing cost [1]. Therefore, the purpose of this retrospective, descriptive study was to determine if analysis of CCC Care Component codes could provide a high granularity signal of early shifts in patient demographics and in nursing care interventions and to, then, determine if nursing care intervention shifts indicated changes in resource utilization. MethodsFor a large multi-facility healthcare system in the USA, patients cared for in an acute care setting/hospital-based care unit were the population of interest. Through prior and ongoing efforts of ensuring Evidenced-Based Clinical Documentation [EBCD], a data model was utilized to determine changes in the patient’s nursing diagnoses, nursing interventions, during care episodes, for patients with acute symptoms or diagnosed/confirmed COVID. ResultsThe structure of CCC revealed 22 billion individual instances of the CCC Care Component/Concept codes for the data sets for 2017 and during COVID, a considerably large data set suitable for pre- and post- event analyses. The component codes were included in a string data set for concept/diagnosis/intervention. DiscussionBy our analysis, these CCC Information Model elements determined a clear ability to detect increasing demands of nursing and resources, prior to other data models, including supply chain data, provider documented diagnostic codes, or laboratory test codes. Therefore, we conclude CCC System structure and Nursing Intervention codes allow for earlier detection of pandemic care nursing resource demands, despite the perceived challenges of “timeliness of documentation” attributed to more constrained timelines of data models of nursing care.

Cost minimization analysis of indication-specific osteosynthesis material in oral and maxillofacial surgery

PurposeFollowing the introduction of the Regulation (EU) 2017/745 by the European Parliament, any bioactive substance or surgical implant introduced into the human body must be documented. The regulation requires any implant to be traced back to the manufacturer. Lot numbers need to be available for every single medical implant. Also, the manufacturer is required by law to provide implants individually packaged and sterilized. Previously, model tray systems (MOS tray) were used for osteosynthesis in oral and maxillofacial surgery, in which the individual implants could not be registered separately. The new regulation made it impossible to use such processes during surgery anymore and a need for a change in the medical practice surged. We examined a possible solution for the new legislation. The aim of this prospective cohort study is to analyze the MOS tray systems to osteosynthesis materials prepackaged in sets. We record and evaluate parameters such as surgical time and documentation time. We perform a short cost analysis of our clinic. The primary aim is to determine how much time is gained or lost by the mandatory increased patient safety. The secondary aim is to describe change in costs.MethodsPatients that underwent standard surgical procedures in the clinic of oral and maxillofacial surgery of the faculty hospital Carl Gustav Carus in Dresden were included. We chose open reduction and internal fixation (ORIF) of anterior mandibular corpus fractures as well as mandibular advancement by means of bilateral sagittal split osteotomies (BSSO) as standardized procedures. Both of these procedures require two osteosynthesis plates and at least four screws for each plate. MOS trays were compared to prepackaged sterilized sets. The sets include a drill bit, two plates, and eight 5-mm screws.A total number of 40 patients were examined. We allocated 20 patients to the ORIF group and the other 20 patients to the BSSO group. Each group was evenly subdivided into a MOS tray group and a prepackaged group. Parameters such as the incision-suture time (IST) as well as the documentation time (DT) by the operating room (OR) staff to complete documentation for the implants are the main focus of investigation.ResultsFor open reduction, the incision-suture time was significantly different in favor of the MOS tray (p < 0.05). There was no difference in the BSSO groups. However, we observed a significantly different (p < 0.01) documentation time advantage for the prepackaged sets in both the ORIF and BSSO groups. On top of that, we find that by using the prepackaged kits, we are able to reduce sterilization costs by €11.53 per size-reduced container. Also, there is also a total cut of costs of €38.90 and €43.70, respectively, per standardized procedure for implant material.ConclusionsBy law, a change in the method of approaching surgery is necessary. For standardized procedures, the right choice of implants can lead to a reduction of documentation time and costs for implant material, sterilization, as well as utilizing less instruments. This in turn leads to lower costs for perioperative processing as well as provision of state-of-the-art implant quality implementing higher patient security.

Education to Improve Point of Care Documentation in Home Care Nurses: A Quality Improvement Project.

Home care nurses are expected to document their care delivery while in the patients' homes. Point of care documentation ensures that information in the EHR is accurate, timely, and accessible to all care team members. Standard training emphasized the features and functions of the different tabs within the electronic record. Managers and nurses reported standard training was not effective. The purpose of this project was to perform a post-implementation evaluation of the incorporation of point of care documentation, using case study scenarios, into the EHR training to determine if there was improved timeliness of documentation by new home care nurses. Quantitative data showed no statistical difference between the pre-implementation and post-implementation participants on completion of documentation within 24 hours from the small sample groups. Quantitative data from training evaluations showed a positive impact on learners' confidence and willingness to complete point of care documentation. Qualitative results showed participants viewed scenario-based training as interactive, meaningful, and indicative of a change in practice to include point of care documentation in the patients' home. The results suggest continued evaluation of the use of scenario-based education with point of care documentation as a format for more effective EHR training.

Improving Fluid Output Monitoring in the Intensive Care Unit.

To assess the potential clinical impact of an automated urine output (UOP) monitoring system in the intensive care unit. Frequency of UOP documentation during a 20-month period was assessed in records of inpatients on the medicine floor, cardiac intensive care (CCU), and cardiothoracic-intensive care units (CTICU). Documentation timeliness (time between expected and observed UOP recording) was assessed over a 3-month period. A novel reusable device that monitors UOP based on continuous analysis of the weight of a urine collection container was tested in the CCU/CTICU. A total of 165,363 UOP measurements were recorded for 2,039 CCU/CTICU admissions. Sixty percent of CCU/CTICU admissions had UOP recorded in the electronic medical record (EMR) less than every 2 hours. One-third of CCU/CTICU measurements were documented more than 2 hours late, and only 10% were recorded less than 20 minutes late. Half of these patients had fewer than 2 measurements recorded per nursing shift and recordings were documented an average of 85 minutes late. There was no significant difference between daytime and nighttime shifts. UOP values obtained by the novel electronic monitoring device were within 27 ml (-224 ml, +228 ml) of nurses documented values, across 74 patients over a 24-hour period. Automating UOP monitoring using a reusable weight-based device is feasible and can improve timeliness of documentation and reduce nursing workload without compromising accuracy.

Evaluation of Standardization of Transfer of Accountability between Inpatient Pharmacists

A compelling body of evidence supports the notion that transfer of accountability (TOA) improves communication, continuity of care, and patient safety. TOA involves the transmission and receipt of information between clinicians at each transition of care. Without a notification system alerting pharmacists to patient transfers, pharmacists' ability to seek out and complete TOA may be hindered. A standardized policy and process for TOA, with automated workflow, was implemented at the study hospital in 2015, to ensure consistency and timeliness of documentation by pharmacists. To evaluate pharmacists' adherence to and satisfaction with the TOA policy and process. A retrospective audit was conducted, using a random sample of individuals who were inpatients between June 2014 and February 2016. Transition points for TOA were identified, and the computerized pharmacy system was reviewed to determine whether TOA had been documented at each transition point. After the audit, an online survey was distributed to assess pharmacists' response to and satisfaction with the TOA policy and workflow. Before the TOA workflow was implemented, TOA documentation by pharmacists ranged from 11% (10/93) to 43% (48/111) of transitions. Eight months after implementation of the workflow, the rate of TOA documentation was 87% (68/78), exceeding the institution's target of 70%. Of the 32 pharmacists surveyed, most were satisfied with the TOA policy and agreed that the standardized workflow was simple to use, increased the number of TOAs provided and received, and improved the quality of completed TOAs. Respondents also indicated that the TOA workflow had improved patient care (mean score 4.09/5, standard deviation 0.64). The standardized TOA policy and process were well received by pharmacists, and resulted in consistent TOA documentation and a TOA documentation rate that exceeded the institutional target.

Improving Documentation Timeliness: A "Brighter Future" for the Electronic Medical Record in Resident Clinics.

Electronic medical records have many observed benefits but may cause work disruption, resulting in delayed documentation completion. The purpose of this project was to improve compliance with institutional standards of documentation of well child checks for residents and attendings without increasing stress. This project was completed at Children's Hospital Primary Care Clinic at Vanderbilt, which is staffed by 74 residents, supervised by 17 attendings. A longitudinal observational study using convenience sampling for the last full week of each month from October 2010-January 2012 was planned. Baseline documentation completion rates were assessed, then age-specific, structured data-entry forms were introduced beginning in March 2011. Run charts were created for completion data for all clinic visits in the sample. Physician self-report of satisfaction with and stress related to documentation was assessed through pre- and postintervention surveys. Data were derived for an average of 231 patient visits per month. The median percentage of documentation or attestations completed within the institutional standards increased from 54.7% to 78.9% for residents and from 38.2% to 83.5% for attendings. Physicians reporting high satisfaction with documentation increased from 20.5% to 85.7% (P < .01) for residents and from 11.1% to 76.9% (P < .01) for attendings. Residents reporting high stress with documentation decreased from 59.1% to 28.6% (P < .02). Use of age-specific, structured data-entry forms achieved marked improvement in documentation timeliness, but there is still room for improvement. The authors are now teaching computer-based documentation in exam rooms and instituting accountability measures.

Mobile solution for clinical research documentation.

153 Background: As trial complexity increases, there is a growing need to facilitate rapid communication of trial data among members of the research and clinical care teams. Timeliness of investigator review and high quality data are critical to clinical trial documentation. Princess Margaret developed an electronic application that meets these needs, is integrated into a patient’s medical chart, and is accessible at the point of care on a mobile device. Methods: Focus groups were held with research staff to evaluate application and device needs. Device needs were usability, compatibility with the electronic patient record (EPR), and encryption ability, which were considered and a device was selected. Standard templates were developed for the informed consent process, clinical notes, vital signs, baseline symptoms, adverse events, and concomitant medications. Electronic source (eSource) was linked to an existing CTMS, the Clinical Research Record. eSource is accessible via the EPR, allows for electronic review and sign off by investigators, and allows data capture directly into the EPR from a mobile device. Results: A 4 month pilot was completed in December 2013 with 10 clinical research nurse coordinators (CRNCs) from 3 different treatment areas, enrolling 40 patients. The project continues to roll out and will be completely integrated by July 2014. CRNCs enter information at the point of care that is easily shared amongst research and clinical care teams; important safety information is available to all staff; investigators can sign off electronically; and data has an audit trail. Metrics collected over a two-month span demonstrate average investigator sign off is completed within 7 days, well under our established timelines of within a cycle of treatment. Conclusions: Enhancements were made within the system during the pilot to facilitate workflow as issues were identified. The system provides solutions for delayed documentation, the transfer of paper charts between team members, and investigator sign-off. This has allowed for tracking of metrics including the timeliness of documentation, review, and sign off; and quality improvements to documentation will be measured through internal quality assurance reviews.

Impact of Homecare Electronic Health Record on Timeliness of Clinical Documentation, Reimbursement, and Patient Outcomes

Homecare is an important and effective way of managing chronic illnesses using skilled nursing care in the home. Unlike hospitals and ambulatory settings, clinicians visit patients at home at different times, independent of each other. Twenty-nine percent of 10,000 homecare agencies in the United States have adopted point-of-care EHRs. Yet, relatively little is known about the growing use of homecare EHRs. Researchers compared workflow, financial billing, and patient outcomes before and after implementation to evaluate the impact of a homecare point-of-care EHR. The design was a pre/post observational study embedded in a mixed methods study. The setting was a Philadelphia-based homecare agency with 137 clinicians. Data sources included: (1) clinician EHR documentation completion; (2) EHR usage data; (3) Medicare billing data; (4) an EHR Nurse Satisfaction survey; (5) clinician observations; (6) clinician interviews; and (7) patient outcomes. Clinicians were satisfied with documentation timeliness and team communication. Following EHR implementation, 90% of notes were completed within the 1-day compliance interval (n = 56,702) compared with 30% of notes completed within the 7-day compliance interval in the pre-implementation period (n = 14,563; OR 19, p <. 001). Productivity in the number of clinical notes documented post-implementation increased almost 10-fold compared to pre-implementation. Days to Medicare claims fell from 100 days pre-implementation to 30 days post-implementation, while the census rose. EHR implementation impact on patient outcomes was limited to some behavioral outcomes. Findings from this homecare EHR study indicated clinician EHR use enabled a sustained increase in productivity of note completion, as well as timeliness of documentation and billing for reimbursement with limited impact on improving patient outcomes. As EHR adoption increases to better meet the needs of the growing population of older people with chronic health conditions, these results can inform homecare EHR development and implementation.

Structured electronic operative reporting: Comparison with dictation in kidney cancer surgery

PurposeThe purpose of this study was to evaluate the functionality of eKidney as a structured reporting tool in operative note generation. To do this, we compared completeness and timeliness of eKidney template-generated nephrectomy OR notes with standard narrative dictation. MethodsA group of academic uro-oncologists and medical informaticians at the University Health Network designed and adopted an electronic online, point-of-care clinical documentation tool, eCancerCareKidney (eKidney) for kidney cancer patient care. The optimal components of clinic and operative note templates, including those for nephrectomy, were agreed upon by expert consensus of the uro-oncologists. Clinician nephrectomy OR reports were analyzed for completeness, comparing those generated in eKidney with conventionally dictated notes. Patterns of missing information from both dictated and eKidney-generated reports were analyzed. The procedure, note completion and transcription dates were recorded which generated time intervals between these events. The records of 189 procedures were included in the analysis. ResultsComparison of clinicians who used both note generation modalities, revealed a mean completion rate of 92% for eKidney/structured notes and 68% for dictated notes (p<0.0001). There was no significant difference in completion rates between attending staff and trainees (residents and fellows) (p=0.131). Most notes were dictated/entered on the day of surgery. Dictated notes were transcribed to EPR a median of 2 days after dictation, however roughly 30% of dictated notes took 5 days or more to get transcribed. All notes generated using eKidney were uploaded to the EPR immediately. LimitationsOur study has three significant limitations. Firstly, our study was not randomized: physicians could elect to dictate or use eKidney. Secondly, we did not identify data from dictated notes that were not captured by eKidney. Third, we did not compare the time it took physicians to complete the fields in eKidney with the time it takes to dictate a note. ConclusionsWe have demonstrated that the use of structured reporting improves the completeness and timeliness of documentation in kidney cancer surgery. eKidney is an example of the power of templates in ensuring that important details of a procedure are recorded. Future studies looking at user satisfaction, and research and educational potential of eKidney would be valuable.

Comparison of the Quality and Timeliness of Vital Signs Data Using Three Different Data-Entry Devices

It is important to evaluate the impact of clinical information systems on the quality and timeliness of documentation in the patient's record to ensure the systems are improving clinical care processes and providing value to the organization. An observational study was conducted to measure the accuracy and timeliness of vital signs data during three different stages of clinical documentation system implementation at a large academic medical center: (1) a paper medical record system, (2) a clinical documentation system with "computers on wheels" workstation outside the patient's room, and (3) a clinical documentation system with a Tablet PC affixed to the vital signs monitor. Patient observations (n = 270) were completed as patient care technicians made routine vital sign rounds. Equipping patient care technicians with a Tablet PC affixed to the vital signs monitor significantly improved (P < .05) the accuracy and timeliness of vital signs. In addition, a number of unintended consequences were discovered that proved helpful to the nurse managers and nursing informatics leadership team in providing support of the new system. Findings from this study emphasize the importance of ensuring that staff has the appropriate devices needed to effectively document patient care at the bedside.

Implications of Event Entry Latency on Anesthesia Information Management Decision Support Systems

Decision support systems (DSSs) are being developed to use events entered in anesthesia information management systems (AIMS) for quality of care, compliance, billing, documentation, and management purposes. DSS performance is impacted by latency from the actual time an event occurs to when it is written to the database, as well as how often the database is queried. Such latencies may result in poor DSS recommendations. We analyzed approximately 48,000 cases at Hospital A for latency of two DSS prototype events, Surgery Begin and Surgery End. Each latency was measured from 1) the time that the event was recorded in the AIMS database as having taken place to 2) the time when the first DSS query would have been executed after the documentation of that event by the provider. The effects on latency of 1, 5, and 10 min query intervals were determined. Latencies for Surgery Begin and Surgery End were compared with those of Hospital B, where a different AIMS was used. Network delays and the event processing time of the AIMS contributed <1 s and 30 s, respectively, to latency. Average latencies for the two studied events were approximately half of the query interval, the expected value if the events occurred randomly within each interval. However, the longest 5% of latencies exceeded the query interval. This was not due to providers editing the times of the Begin or End Surgery events, as each occurred in only 0.7% of cases. Although the median latencies for the two events were longer at Hospital B than Hospital A by a few minutes, the 90th and 95th percentiles of the latencies were much longer at Hospital B (8-30 min, depending on the query interval and the percentile). DSS performance is influenced by the timeliness of documentation, the incidence of missing documentation and the query interval. Facilities using a DSS, including electronic whiteboards showing patient status, should assess the latencies of the measured events and critique the influence of the latencies on clinical and managerial decisions.

The Medicolegal Importance of Enhancing Timeliness of Documentation When Using an Anesthesia Information System and the Response to Automated Feedback in an Academic Practice

The Medicolegal Importance of Enhancing Timeliness of Documentation When Using an Anesthesia Information System and the Response to Automated Feedback in an Academic Practice

Monitoring the Quality of Contracted Therapy Services Provided by a Vendor: A Model for Home Health Services

Many home health care agencies contract with outside vendors to provide some services, such as occupational and physical therapy. The agency, however, must assure the quality of these contracted services. Rush Home Health Service has developed a system for monitoring the quality of care provided by a vendor of rehabilitation services. The system focuses on seven aspects of care provided by the vendor: referral response time, contract therapists' records, visit attempts, timeliness of documentation, presence of required documentation, content of documentation, and the quality of care (goals reached, continuity of care, and patient satisfaction).